Total Wrist Arthroplasty: An International Perspective.

Concerns about implant durability and technical difficulty continue to make total wrist arthroplasties a specialized procedure with a narrow scope of indications. As a result, more routinely performed total or partial wrist arthrodesis continues to maintain popularity over arthroplasty. However, wrist motion preservation is undoubtedly preferable for patients and current literature is trending to more favorable outcomes for total wrist arthroplasties. In the setting of the evolving role of wrist arthroplasties in clinical practice, it is important to focus on providing hand surgeons a practical approach to incorporating total wrist arthroplasty into the treatment toolbox available to them when treating patients with painful wrist arthritis.

The Use of Nerve Caps after Nerve Transection in Headache Surgery: Cadaver and Case Reports.

Background: Nerve transection with nerve reconstruction is part of the treatment algorithm for patients with refractory pain after greater occipital nerve (GON) and lesser occipital nerve (LON) decompression or during primary decompression when severe nerve injury or neuroma formation is present. Importantly, the residual nerve stump is often best addressed via contemporary nerve reconstruction techniques to avoid recurrent pain. As a primary aim of this study, nerve capping is explored as a potential viable alternative that can be utilized in certain headache cases to mitigate pain. Methods: The technical feasibility of nerve capping after GON/LON transection was evaluated in cadaver dissections and intraoperatively. Patient-reported outcomes in the 3- to 4-month period were compiled from clinic visits. At 1-year follow-up, subjective outcomes and Migraine Headache Index scores were tabulated. Results: Two patients underwent nerve capping as a treatment for headaches refractory to medical therapy and surgical decompressions with significant improvement to total resolution of pain without postoperative complications. These improvements on pain frequency, intensity, and duration remained stable at a 1-year time point (Migraine Headache Index score reductions of -180 to -205). Conclusions: Surgeons should be equipped to address the proximal nerve stump to prevent neuroma and neuropathic pain recurrence. Next to known contemporary nerve reconstruction techniques such as targeted muscle reinnervation/regenerative peripheral nerve interface and relocation nerve grafting, nerve capping is another viable method for surgeons to address the proximal nerve stump in settings of GON and LON pain. This option exhibits short operative time, requires only limited dissection, and yields significant clinical improvement in pain symptoms.

Syndactyly Release in the Hand: Surgical Technique.

SUMMARY: Syndactyly is one of the most common congenital differences treated by hand surgeons. Although dozens of techniques for syndactyly release have been described, a reliable method is based on a dorsal rectangular flap for commissure construction and a combination of interdigitating zigzag flaps and skin grafts for digital coverage. In this article, the authors present a detailed description of syndactyly release emphasizing principles integral to successful outcomes.

Assessment of Plastic Surgery Residency Applications without United States Medical Licensing Examination Step 1 Scores.

SUMMARY: The United States Medical Licensing Examination announced the changing of Step 1 score reporting from a three-digit number to pass/fail beginning on January 1, 2022. Plastic surgery residency programs have traditionally used United States Medical Licensing Examination Step 1 scores to compare plastic surgery residency applicants. Without a numerical score, the plastic surgery residency application review process will likely change. This article discusses advantages, disadvantages, and steps forward for residency programs related to the upcoming change. The authors encourage programs to continue to seek innovative methods of objectively and holistically evaluating applications.

The Impact of Social Media on Plastic Surgery Residency Applicants.

BACKGROUND: Plastic surgeons have been early adopters of social media, and the efficacy and ethics of this practice have been studied. In addition, plastic and reconstructive surgery (PRS) training programs have begun using social media to connect with the public, including prospective PRS applicants. The ability of social media to attract prospective residency applicants is unknown. This study aims to examine the influence of social media on prospective residency applicants and their perception of a plastic surgery program. METHODS: In the academic years 2018 and 2019, we conducted an anonymous, voluntary survey among applicants applying to both the integrated and independent Harvard PRS residency programs. The survey collected data regarding demographics, social media usage, online information gathering, and PRS programs' social media influence on applicants' perception/rank position of programs. RESULTS: One hundred nine surveys were completed (23%). Ninety-seven percent of respondents reported searching online for information about residency programs. Twenty percent of respondents noted that a residency program's social media platform "influenced their perception of a program or intended rank position of a program" and 72% of those respondents indicated a positive effect on their perception of a program and its rank list position. At least 15% of respondents were concerned that engaging with a program's social media account would attract attention to their own social media accounts. CONCLUSIONS: Applicants routinely rely on online resources to gather information regarding prospective residency programs. Fear of attracting attention to their own personal social media pages may limit applicants' engagement with PRS programs on social media. However, residency programs can still utilize social media to deliver important messages, especially as social media usage continues to grow.

Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction in the Setting of Cryolipolysis.

The deep inferior epigastric artery perforator (DIEP) flap is a safe and reliable autologous breast reconstruction option for patients undergoing surgical treatment for breast cancer. Success of the procedure relies on adequate flap perfusion from perforators that travel within the subcutaneous layer of the abdominal wall. Patients who have undergone invasive abdominal wall procedures such as suction-assisted liposuction may therefore be at increased risk of postoperative complications such as flap loss and fat necrosis. In recent years, noninvasive fat-reduction techniques such as cryolipolysis have grown immensely in popularity. However, there are no data regarding outcomes for patients who have undergone DIEP flap breast reconstruction after having previously undergone abdominal cryolipolysis. The current case demonstrates that free flap breast reconstruction can be performed safely in this patient population, and that adjunct imaging modalities may improve clinical decision-making.

Webinar during COVID-19 Improves Knowledge of Changes to the Plastic Surgery Residency Application Process.

BACKGROUND: The COVID-19 pandemic has significantly impacted residency application process for all specialties, including plastic surgery residency. Almost all plastic surgery residency programs have suspended visiting sub-internship rotations. This study quantifies the impact of a webinar through an analysis of poll questions and a post-webinar survey sent to all registered participants. METHODS: A dedicated webinar was organized and held by the Harvard Plastic Surgery Residency Training Program. All attendees were asked several poll questions during the webinar. The 192 participants were also sent a post-webinar survey. RESULTS: The response rate was 68.2% (n = 131). Respondents were more confident about matching into a plastic surgery residency program at the end of the webinar compared with before the webinar (P < 0.001). Respondents who did not have a plastic surgery residency program at their home institution were less confident at the start of the webinar (P = 0.009). In addition, respondents who had not taken time off for research or for other endeavors during or after medical school were less confident about their chances to match at the start of the webinar (P = 0.034). CONCLUSIONS: An online webinar program increased confidence levels of medical students interested in applying for residency positions in plastic surgery. Residency programs should consider webinars as a method to inform and assist medical students during the upcoming application season.

Closed Incision Negative Pressure Wound Therapy After Resection of Large, Radiated, Soft Tissue Sarcomas.

Negative pressure wound therapy (NPWT) has revolutionized wound care. Negative pressure therapy (NPT) is now being applied to closed incisions. Closed-incision NPT (ciNPT) management systems apply negative pressure to the incision and structurally stabilize the surrounding tissues. They are thought to be helpful in high-risk surgical closure. Patients with large sarcomas that have been previously radiated are considered to be among the highest risk for postoperative wound complications. We share our experience with ciNPT in two patients after resection of large, previously irradiated invasive sarcomas. In both cases, healing was uncomplicated. ciNPT shows promise of effective and favorable wound healing in early case reports. Additional prospective randomized clinical trials or registry studies will be necessary to provide higher levels of evidence for this technique.

Preoperative Anemia Is Associated With Failure of Open Debridement Polyethylene Exchange in Acute and Acute Hematogenous Prosthetic Joint Infection.

BACKGROUND: Acute and acute hematogenous prosthetic joint infections (PJIs) are often treated with open debridement and polyethylene exchange (ODPE) in an effort to save the prosthesis, decrease morbidity, and reduce costs. However, failure of ODPE may compromise a subsequent 2-stage treatment. The purpose of this study is to identify patient factors that impact the success of ODPE for acute and acute hematogenous PJIs. METHODS: A retrospective review examined comorbidities, preoperative laboratory values, and patient history for patients with successful and failed ODPE treatment for acute perioperative or acute hematogenous periprosthetic hip or knee joint infections. Successful treatment was defined as retaining a well-fixed implant without the need for additional surgery for a minimum of 6-month follow-up with or without lifelong oral maintenance antibiotics. RESULTS: Fifty-three of 72 patients (73.6%) underwent successful ODPE. Of the 19 failures, 14 completed 2-stage revision with one subsequent known failure for recurrent infection. Patients with a Staphylococcus aureus infection were more likely to fail ODPE (48.3% vs 11.6%, P = .0012, odds ratio 7.1, 95% confidence interval 2.3-25.3). Patients with a preoperative hematocrit ≤32.1 were also more likely to fail ODPE (55% vs 16%, P = .0013, odds ratio 6.7, 95% confidence interval 2.2-22.4). When neither risk factor was present, 97.1% of PJIs were successfully treated with ODPE. CONCLUSION: S aureus infection and preoperative hematocrit ≤32.1 are independent risk factors for ODPE failure. ODPE is a safe alternative to 2-stage revision in patients without preoperative anemia and without S aureus infection. Two-thirds of patients with a failed ODPE were successfully treated with a 2-stage reimplantation.